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Community Food Initiatives Retailing in Hospitals and Health Centres

About CFHS

Community Food and Health (Scotland) or CFHS aims to ensure that everyone in Scotland has the opportunity, ability and confidence to access a healthy and acceptable diet for themselves, their families and their communities. We do this by supporting work with and within low-income communities that addresses health inequalities and barriers to healthy and affordable food.

Barriers being addressed by community-based initiatives are:

Availability – increasing access to fruit and vegetables of an acceptable quality and costAffordability – tackling not only the cost of shopping but also getting to the shopsSkills – improving confidence and skills in cooking and shoppingCulture – overcoming ingrained habits

Through our work we aim to support communities to:• identify barriers to a healthy balanced diet• develop local responses to addressing these barriers, and• highlight where actions at other levels, or in other sectors, are required.

We value the experience, understanding, skills and knowledge within Scotland’s community food initiatives and their unique contribution to developing and delivering policy and practice at all levels.

Acknowledgements

We would like to thank everyone who provided CFHS with information about their stalls in hospitals and health centres. Thanks also to the community food initiatives that provided some of the photographs included.

Contents

Section 1Setting the scene page 5

Section 2Why retailing in hospitals? page 8

Section 3 What is the impact? page 10

Section 4 Factors that influence the success of stalls page 11

Headline findings

The hospital stalls that are most successful would appear to be those that are supported by a wide range of hospital staff. Below are some factors that have enabled community food initiatives to operate stalls successfully within hospitals and health centres:

• hospital management staff recognising the wide-ranging benefits that providing access to fresh produce brings for staff, visitors and patients;• hospital management staff being flexible, responsive and innovative;• having an identified lead contact within health promotion/improvement teams in addition to any relationships created with management;• using opportunities through hospital intranet sites, events, and partnership working to promote the stalls, the access to healthy produce they provide, and their affordability;• stall opening hours that reflect visiting times and staff shift patterns;• NHS funding to purchase equipment (eg. pergolas to enable stalls to operate outside, display stands, etc), and marketing materials, (eg. ‘table-toppers’ and pull-up banners); and• rent-free space in which to operate the stall.

While all of the stalls in this report were established with the aim of becoming financially self-sustaining, few were generating a profit. Most of the stalls received short-term funding to enable them to cover their costs while they built up a customer base, but several stopped running when this funding ceased.

Some stalls might not attract sufficient customers to become financially viable; however, commitment of time and resources is more likely to ensure that this happens. Additional factors that could further support community food initiatives to operate stalls successfully within hospitals and health centres are:

• funding to set up stalls and enable them to establish a customer base;• provision of storage space to enable stalls to open for longer hours and potentially more frequently;• recognition of the need to ensure a prime location for stalls to attract customers; and• exploration of procurement models and potential collaboration between community food initiatives and catering facilities.

Setting the sceneIntroductionAcross Scotland, many community food initiatives are involved in community retailing, ie. selling good quality, affordable food in community-based settings. Most focus on selling fruit and vegetables, often exclusively.

In the last few years, a small but increasing number of community food initiatives have become, or have set up, social enterprises1 and expanded their retailing activities to include selling commercially to private sector customers, both corporate and individual. Retailing in this way allows community food initiatives to generate income that can then be used to support their food and health activities within low-income and disadvantaged communities.

Community Food and Health (Scotland) became aware that some community food initiatives had extended their retailing activities into hospitals and health centres. We wanted to find out more about this work; what they were doing and why, what support they had received and how they had overcome any difficulties they had faced.

This publication explores the factors that have influenced the success of these stalls, the policy drivers that have supported them and the ‘win-win’ that can be created through partnership working. It has been produced to highlight and share the good practice gathered from discussions with both community food initiatives involved in retailing in hospitals, and NHS staff. It highlights the factors that have contributed to the stalls’ successes, and the challenges that both community food initiatives and NHS staff have overcome.

We hope that this publication will encourage other community food initiatives and NHS boards to consider what opportunities there may be to work together to establish similar services in their areas.

BackgroundIn January 2010, CFHS held a round table discussion about retailing in hospitals. Representatives from three community food initiatives (from Edinburgh, Lanarkshire and Aberdeen), two NHS Boards (NHS Forth Valley and NHS Dumfries and Galloway) and a Council for Voluntary Service (Falkirk) took part. All of them had experience of setting up and running fruit and vegetable outlets in a hospital setting, or hoped to do so in the future. While the discussion highlighted that the outlets were all very different, it revealed a number of common features and identified some common issues that they faced. A report of the round table discussion is available on the CFHS website.

Following the round table discussion, CFHS became aware of other community food initiatives that were involved in hospital retailing, including those in Inverclyde, Dundee and Tayside, Inverness, and Fife. Between March and July 2010 CFHS staff visited or contacted staff from community food initiatives and NHS boards to find out more about the stalls operating in these eight NHS board areas. They were asked the following:

• Why retailing in hospitals?• What impact do the stalls have?• What factors influence the success of the stalls or create challenges for their operation?

This publication condenses the key points from the discussions and conversations that took place. It also includes examples to highlight some of these key points.

1 A social enterprise is a business that has been set up to address social or environmental needs. The profits made are reinvested in the business or in the community.

About the community food initiatives includedWhile this publication was being produced, some of the community food initiatives ceased operating or ceased their hospital retailing. However, their experience of hospital retailing remains valuable, and, therefore, examples of some of their work have been included.

The allotment was a fruit and vegetable shop in Dumfries, established by Nithsdale Council for Voluntary Service and NHS Dumfries and Galloway in autumn 2008. For six months in 2009 a staff member and volunteer ran a weekly fruit and vegetable stall in Dumfries and Galloway Royal Infirmary. This service ceased when the allotment closed in early 2010.

The Big Apple is the social enterprise arm1 of Transform Community Development. The organisation runs fruit and vegetable stalls in four hospitals in the NHS Tayside and NHS Fife areas. A stall in Ninewells Hospital in Dundee operates once a week in the spring and summer. It also runs stalls weekly in Queen Margaret Hospital in Dunfermline, and the Victoria and Forth Park Hospitals in Kirkcaldy. The stalls are open for four to five hours each day.

The Big Apple ran stalls in three other hospitals in the NHS Tayside area, in Perth Royal Infirmary and Stracathro and Kings Cross Hospitals, but stopped doing so because of poor sales.

CFINE (Community Food Initiatives North East) operates fruit and vegetable outlets in three hospitals in the NHS Grampian area. All the outlets operate for three to four hours each day. In Aberdeen Royal Infirmary the outlet was originally open three days a week, but is now open twice a week. There is also an outlet open once a week in Cornhill Hospital. CFINE is piloting an additional stall in the children’s hospital in Aberdeen. For a time it also provided a fruit and vegetable delivery service for staff working in Woodend Hospital and a stall in Dr Gray’s Hospital in Elgin. Community Food Moray now runs the stall in Dr Gray’s, and in Seafield Hospital in Buckie and Steven’s Hospital and Health Centre, Dufftown.

CFINE also supports community food co-ops and outlets in West Lothian, including one operating in St John’s Hospital. This outlet was previously supported by Welfehd, a community food initiative that ceased trading in 2009.

Edinburgh Community Food (ECF) runs a stall in four NHS Lothian premises. It operates a stall two days a week in the Western General Hospital, and once a week in the Royal Edinburgh Hospital, NHS premises in Lauriston Place, and Edinburgh Royal Infirmary. The stalls are open from 8 am to 2 pm or 3 pm. For some months it also ran a stall in the Astley Ainsley Hospital, but closed this because of low customer numbers. Staff are hoping to resume running stalls three times a week in the Western General Hospital, when a new building opens in 2012.

Lanarkshire Community Food and Health Partnership (LCFHP) was the first community food initiative to open a fruit and vegetable stall in hospital premises. Through Fruits and Roots, its social enterprise arm, it now runs stalls in three acute hospitals in the NHS Lanarkshire area. In Monklands General Hospital in Airdrie the stall is open four days a week, for four hours. In Wishaw General Hospital, where it runs twice a week, the stall is open for six hours per day. There is also a stall operating once a week in Hairmyres Hospital in East Kilbride for four hours. LCFHP also runs fruit and vegetable access points in the Corporate Services Building at Monklands General Hospital, Coatbridge Health Centre and Viewpark Health Centres. It ran stalls in other health centres across North and South Lanarkshire, but was unable to continue to do so without ongoing financial support.

REAL Food is a community food initiative based within Inverness High School. Until October 2010 it ran community retailing outlets across the city in addition to the market garden that is based at the school. One of the outlets was in Raigmore Hospital, NHS Highland. While its retailing activities have ceased, its market garden continues.

1 Charities and charitable organisations that are registered companies can set up subsidiary companies to enable them to carry out non-charitable trading activities. These subsidiary companies can be called social enterprise arms, trading arms or trading subsidiaries. The subsidiary companies are wholly-owned by the charities or charitable companies that set them up. Any profits made by a trading subsidiary are gifted back to the charity or charitable company.

Stepwell Ltd runs Mobile Markets at Inverclyde Hospital and Greenock Health Centre in the NHS Greater Glasgow and Clyde area. The Markets sell pre-packed fruit bags and soup bags only. The cost of running these stalls and six others in the Greenock area are partially met with funding from the local Community Planning Partnership, the Inverclyde Alliance.

How do the stalls operate? The purpose of the stalls is to encourage staff, visitors and patients to purchase, and eat, more fruit and vegetables. However, all of the stalls are being run to generate income for the community food initiatives.

The structures of the community food initiatives running the stalls differ. Some are charities, others are charitable companies. Some have established trading arms to run their commercial activities (including the hospital stalls). For all, their legal structures ensure that the income generated from the stalls is used to further their charitable aims.

While all of the community food initiatives sell the produce on the stalls for more than they buy it for, they aim to sell their produce at rates that are lower than or comparable with commercial retailers. The mark-up added by each initiative varies and is between 20% and 35% of the purchasing costs. If the cost of buying some staple products, eg. bananas, is very high, some initiatives may sell these at a loss to encourage custom.

In addition to improving access to fruit and vegetables, the stalls are providing employment and training opportunities. Both paid workers and volunteers staff the stalls, with some community food initiatives employing part-time staff solely to work on their stalls. One stall provided places for Future Jobs Fund trainees.

Between them, the community food initiatives included are currently running stalls in 19 hospitals and health centres. The number of hours that the stalls operate for varies from hospital to hospital, but most are open from the morning until afternoon visiting time. Some stalls are sited near the main entrance to the hospital while others are placed in different locations within the hospital building. In three hospitals the stalls run outside the main entrance. Most of the customers buying from the stalls are staff, but visitors and patients also buy from them.

Unlike other businesses operating in hospitals, none of the community food initiatives have to pay rent for their stalls. Some of the community food initiatives have service level agreements1 with the relevant NHS Board, whilst others operate with a more informal relationship.

2 A service level agreement is part of a service contract where the level of service is formally defined.

For all the partners, the timing and the policy environment were right.

Some community food initiatives had recognised the potential for generating income through expanding their community retailing into hospitals and health centres. Independently, some NHS staff had also been pursuing establishing fruit and vegetable stalls in health service premises. Working closely with their local community food initiatives, they knew that these had expertise in selling fruit and vegetables and encouraging people to buy, prepare and cook them. As a result some initiatives and some hospital staff had been pursuing hospital stalls for some time; however, they had been unable to establish them. The developing policy environment has resulted in a range of policy initiatives that have provided impetus for retailing healthy produce in hospitals and health centres.

The Health Promoting Health Service In March 2008, Chief Executive’s Letter 14 (CEL 14) to NHS Boards advised that they are expected to make their hospitals health promoting through implementing the Health Promoting Health Service (HPHS) Framework. Action 10.4 in CEL 14 is one of the six specific actions that NHS Boards were expected to implement:

10.4FoodandHealth:increaseaccesstocompetitivelypricedfruitandvegetablesthroughretailoutletsinacutesettings

In May 2010 the Scottish Government and NHS Scotland re-affirmed their commitment to pursuing the health improvement activities of the Health Promoting Health Service in the Healthcare Quality Strategy for NHS Scotland.

Why retailing in hospitals?

Other policy drivers In addition to the HPHS framework, other policies have provided further opportunities to explore community retailing in hospitals.

In 2009 the Obesity Route Map1 identified the need to create supportive environments to encourage people to eat healthily. In particular, the responsibility of organisations to improve the health and wellbeing of their employees has been identified.

In 2007, the Scottish Government launched ‘Scotland Performs’, a national performance framework designed to capture change and progress against priority issues for Scotland. Fifteen national outcomes have been identified within this framework, three of which are most relevant to hospital stalls:

‘Welivelonger,healthierlives.’

‘Weliveinwell-designed,sustainableplaceswhereweareabletoaccesstheamenitiesandservicesweneed.’

‘Ourpublicservicesarehighquality,continuallyimproving,efficientandresponsivetolocalpeople’sneeds.’

Healthy Working Lives is an award programme that supports employers to develop health promotion and safety within the workplace. The programme is tiered with bronze, silver and gold awards. There are local Healthy Working Lives teams within each Health Board across Scotland that provide a clear link to promoting healthy eating to hospital staff and those working in health centres. Some of the teams also support access to fresh produce through schemes like “Fruity Fridays”, which source produce through the projects mentioned above.

Each NHS Board has a delivery agreement with the Scottish Government that is based on the key objectives, targets and measures that reflect Minister’s priorities for health. Within this, NHS Performance Targets have been set for Scotland, otherwise known as HEAT targets. Within the efficiency targets for 2011/12, all NHS Boards are required to ‘reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009.’

The convergence of all of these factors provided the opportunity for community food initiatives and hospitals to work together.

In2009staffonthecolorectalwardinStJohn’sHospitalinLivingstondecidedtoputintopracticethedietaryadvicethattheyweregivingtheirpatients.Thewardbecamea‘sweet-freezone’.Patients,visitorsandstaffwereaskednottobringsweetsontotheward.Tosupportthechanges,asurgeondonatedaboxoffruitforthestafftoeateveryweekfor12weeks.Attheendofthisperiodthestaffstatedthattheyfelthealthierandsomereportedthattheyhadlostweight.

UsingthispositiveexperienceofstafffromStJohn’sHospital,ahealthimprovementofficerinAberdeenRoyalInfirmarywaskeentomakeiteasierforhospitalstafftobuyfreshfruitandvegetables.SherecognisedthatCEL14couldbeusedasalevertodothis,andthatincreasingaccesstofreshproducewouldlinkwellwiththehospital’sHealthyWorkingLivesprogramme.

CFINEhadbeenkeenforanumberofyearstoestablishfruitandvegetablestallsinhospitals.CFINEsawthisasanaturalextensionofitswork,whichwassupportingcommunityfoodoutletsacrossAberdeen,AberdeenshireandMoray,andCFINEstaffhadmadetentativeapproachestohospitalstaffinthepast.Whenapproached,theywelcomedtheopportunitytorunastallatthehospitalforathree-monthtrial.

Thestall,whichopenedinJune2009,isstillrunning.CFINEnowrunsstallsintwootherhospitalsandispilotinganotherinathird.Anevaluationofthestallhighlightedthatitissupportingstafftomakepositive,andmeasurable,changestotheirlifestyles.

Thesuccessofthestallcanbeaccreditedtothecommitmentofeveryoneinvolved,includingthebuy-infromthehospitalmanagement.Becausetheexperiencehasbeensopositive,thehospitalisnowtargetingotherhealthpromotionissues.

1 Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight, Scottish Government 20092 H – Health Improvement; E – Efficiency; A – Access and T - Treatment

2

What impact do the stalls have?

In order to demonstrate their impact, four of the community food initiatives had carried out evaluations of their hospital retailing work in the previous three years – CFINE, LCFHP, the allotment in Dumfries and the Big Apple.

All four used questionnaires designed to capture the specific impact of the stalls for staff, patients and visitors. They were distributed to customers visiting the stalls, or to hospital staff electronically. The questionnaires included issues around perceptions of the stall, impact on consumption of fruit and vegetables and the knowledge and understanding of the recommended portions of fruit and vegetables to be eaten each day.

Three initiatives reported the number of questionnaires that were completed and on average there were 213 respondents. Most respondents were hospital staff, ranging from 51% to 86%.

When asked how frequently people shopped at the stalls, the evaluations found that customers were most likely to shop at the stalls weekly (av. 39%) or fortnightly (25%).

Three evaluations specifically explored what motivated customers to shop at the stalls. One found price (44%), quality (44%) and availability (43%) were the main factors that motivated customers. Another evaluation found that location/convenience was the main reason customers used the stall. Only 20% of customers reported that they shopped at the stall because of the competitive prices. The third evaluation found that quality, location and the sale of local produce were key reasons why people shopped at the stalls. Other evaluations further explored the issue of price and found that the prices on the stall were largely perceived to be cheap or fair.

The evaluations also found that customers were eating more fruit and vegetables, with the increase in consumption ranging from 13% to 51%. One evaluation also found that customers had increased the range of fruit and vegetables they were eating.

In relation to learning for the future, two evaluations specifically explored any suggestions for improving the stall. The list below is a sample of the suggestions.

• Ensuringpricesarecompetitive• Increasingthechoiceofproduce(including flowersandherbs)• Locatingtomoreobviousposition• Increaseopeninghours• Increaselocalproduceavailable• Specialoffers• Openallyear• Increasepublicity• Ensuregoodquality• Fruitbags/ready-to-eatproduce• Recipecards One evaluation specifically explored why people had not shopped at the stall before and found that some staff did not have enough time, some felt it was too expensive and others already brought fruit and vegetables from home. One evaluation also asked about the online ordering service it provided, finding that 28% of people knew about the service and, although very few had used it previously, 51% said they would use it in future.

Two stalls included profit and loss information within their evaluations. This highlighted that ongoing sustainability was a key issue. Both stalls received funding for the year in which the evaluation was carried out. However, they identified that their profit margins would not support a self–sustaining model of operation. Whilst some initiatives were making good profits, for example during summer months or at certain hospital sites, this was counteracted by other losses.

Factors that influence the success of the stalls

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Thefollowingsectionhighlightsthemainfactorsthathavehadaninfluenceonthesuccessofthefruitandvegetablestalls,andincludesexamplesofhowthesehaveaffectedtheworkofthecommunityfoodinitiatives.Thefactorshavehadadifferentimpactforeachofthestalls;however,theyareallsignificant.Whiletheseexampleshavebeenclustered,manyoftheexamplesillustratemorethanonefactor.

All of the stalls operate with the consent of the NHS Board and hospital management. However, the stalls that run most successfully have active management support of both. The most successful stalls are running in hospitals where the management recognises the wide-ranging benefits that providing access to fresh produce brings for staff, visitors and patients.

Where community food initiatives have been successful in setting up and sustaining stalls, support from management was found to be flexible in nature, responsive to the needs of both the community food initiative and its customers, and innovative in its approach.

The most significant support provided by the hospitals is the allocation of space for the stalls.

Sinceopeningin2009,thestalloperatedbyECFintheRoyalEdinburghHospitalhasbecomeverymuchpartofthelifeofthehospital-“in with the bricks...part of the family”.

Settingupthestallhadbeenverystraightforward-“had been no health and safety issues – management had used common sense.”

Thestallwasestablishedshortlyaftertheappointmentofanewhospitaldirectorwhowantedtobring‘communitiesintothehospital’.Inadditiontothissupport,thehospitalalsohasaveryactiveHealthandWellbeingGroupforbothstaffandpatients(evolvedfromaHealthyWorkingLivesgroup).Thestallisseenasakeypartoftheiractivities.

Thisstallisthoughttobetheonlyoneoperatingwithinapsychiatrichospital.Someoftheotherbenefitsthatthestallbringstothehospitalareexploredlaterinthisreport.

However, some community food initiatives have had limited support from management, which has resulted in difficulties in setting up and establishing a stall.

Some hospitals are Public-Private Partnership (PPP) hospitals. Because several companies may be involved in the management of the buildings and facilities, it may be more difficult for community food initiatives to identify who they should be negotiating with, or take longer to reach agreement about where and how a stall may operate.

OnecommunityfoodinitiativegainedagreementinprincipletoestablishastallwithinaPPPhospital;however,itwasdifficulttodeveloprelationshipswiththerelevantstafftomakethishappen.

Inanotherhealthboardarea,ahealthpromotionofficerstruggledtogainagreementfromsomeofthemanagementtogoaheadandestablishastall.Theseissueswerelargelyduetoarrangementswithotherretailerswithinthehospitalsitesandconcernsaroundcreatingcompetition. None of the stalls would have been established without strong and effective partnership working. Many of the examples included in this publication highlight this explicity or implicity. For all of the community food initiatives, the working links were forged initially with NHS health promotion or health improvement staff. Without these, it is unlikely that the stalls would have been established as quickly. All also work closely with other partners, some within the NHS, some from other organisations. The added value that this partnership working brings to the hospital retailing was highlighted by both community food initiatives and NHS staff.

LCFHPwasabletoprovidesix-monthworkopportunitiesforthreeunemployedlocalpeoplefundedthroughtheFutureJobsFund.ThethreetraineesranorworkedonthehospitalandhealthcentrestallsrunbyLCFHP,forpart,orall,oftheirplacement.Whiletheadditionalstaffingcapacitywaswelcome,managingtheplacementsincreasedtheworkloadforLCFHP’sstaff.

WorkingcloselywithECFandstafffromtheRoyalEdinburghHospital,EdinburghVolunteerExchangesupportsasmallnumberofpatientstovolunteerwithECF’sfruitandvegetablestall.Thevolunteersdeliverfruitandvegetablebagstoseveralwardsinthehospital.

ECFisinvolvedinactivitiesrunbystaffandotherorganisationswithintheRoyalEdinburghHospital.Inadditiontodonatingprizesforhospital-runraffles,ittakespartinotherevents.Inthepastthishasincludeddistributingapplesfromthehospital’sorchard.

CFINE’sstallatDrGray’sHospitalissitedoutsidethemainentrance.NHSGrampianhasprovideditwithfundingtopurchaseapergolatoprotectthestafffromtheworstoftheweatherandapullupbannertopromotethestall.

FollowingtheestablishmentofCFINE’sstallattheAberdeenRoyalInfirmary(ARI),theHealthImprovementOfficerworkingwithCFINEwaskeentopromoteitsworkfurther,andencouragemorepatientstousethestalls.ShewasindiscussionwithotherNHSstaffandCFINEaboutincludingvouchersforthestallsintheBountypacksgiventonewmothers.Shewasalsoapproachedbythesubstancemisusemidwifeaboutpromotingthestallstothefamiliesusingthisservice.ThisendorsementhashelpedembedthestallatARI.

TheHealthyWorkingLivesprogrammeinARIorganiseslunchtimewalksforhospitalstaff.Asanincentivefortakingpart,participantsreceiveavoucherforapieceoffruit,redeemableatCFINE’sstall.InreturnCFINEdonatesapercentageofitssalestotheHealthyWorkingLivesendowmentfund.

TheallotmentinDumfriesworkedcloselywithNHShealthpromotionstaff,whorantastingandcookerysessionsusingproduceavailablefromthefruitandvegetablestall.

One particular issue that effective partnership working and management support has helped some community food initiatives to overcome has been around challenges associated with infection control. For some of the community food initiatives, particularly those running stalls in acute hospitals, this has affected:

• where the stalls are sited, eg. operating on hospital grounds outside or within the vicinity of running water;• what produce they sell, eg. selling produce in sealed bags or not being able to sell ‘dirty’ produce; and/or• how they sell their produce, eg. most stalls are not allowed to prepare (chop or peel) their produce on the stall.

NHSGrampianaskedCFINEtosetupandrunastallinARIthreetimesaweek.Whilethehospital’sseniormanagementwereverysupportive,CorporateCommunicationswereconcernedaboutinfectioncontrol.Initially,CFINEwasnotpermittedtosetupitsstallwithinthehospitalbuildinganditwaslocatedoutsidethemainentrance,wheresalesweregood.Fromtheoutsetitinvolvedthefire,healthandsafetyandsecurityteams.Withtheirsupportand,crucially,supportfromahealthpromotionofficerandtheirmanager,themanagementteamwasreassuredthatlocatingthestallinthebuildingwasnotgoingtopresentinfectioncontrolproblems.CFINEhassincemovedthestallinside,albeittoalocationthathasfewerfootfallsthanitsoutdoorsite.Itnowoperatesthestallindoorduringthecoldermonths,andoutdoorsduringthewarmermonths.

UntilSeptember2010REALFoodwasinvolvedinretailingandrananumberoffruitandvegetablestallsandoutletsintheInvernessarea,includinginRaigmoreHospital.Ithadbeenoperatingthisstallverysuccessfullyforsometimewhenitwasaskedtomoveitelsewhereinthehospital,becauseofconcernsatNHSBoardlevelaboutinfectioncontrol.The

stallwasthensitedinanareawithmuchlessfootfall,and,asaresult,itsincomedroppedsignificantlyanditsopeninghourswerereduced.

TheBigApple’sstallinNinewellsHospitaloperatesfromamarqueesituatedintheFreshAirGardenbesidethehospital.Ithasnotbeenallowedtosetthestallupwithinthehospitalbuilding,againbecauseofinfectioncontrolconcerns.Thestalldoesnotoperateduringthecolderweather,whichadverselyaffectsitsabilitytoretainitscustomers.

Stepwellisonlyallowedtosellpre-baggedproducefromitstwostallsoperatinginNHSpremises. In addition to infection control, management have also identified other concerns such as competition with other retailers. Many community food initiatives are operating within hospitals where there are other retailers. One particular issue is that some community food initiatives market their produce as ‘healthy gifts’ for patients. One community food initiative is not allowed to sell pre-packed produce as this creates direct competition with other retailers who also sell gifts.

Both infection control and competition with other retailers strongly influence where the stalls are located. However, location itself is also a key issue that was highlighted by all the community food initiatives. Location has a direct affect on the amount of footfall passing a stall and as a higher footfall creates greater opportunities to sell produce, location also has a direct impact on the income that community food initiatives can generate.

ECFestablishedanewstallintheAstleyAinsliehospitalinsummer2010.Thisstallwasoriginallysetupwithinasideroom,adjacenttothestaffcanteen.Itwasnotsuccessfulbecauseitwasoutofviewofstaffusingthecanteen.Attheinstigationofthecateringmanager,thestallwasmovedintothecanteen.Whilethisattractedmorecustomers,and

positivefeedbackfromthehospitalstaff-‘good comments, good vibes’ –thenumberofcustomersdidnotincreasesufficientlytomakethestallfinanciallysustainable.Itwasclosedafterseveralmonths. While no stalls are required to pay rent for the space they use within the hospital sites, all but one are required to clear away their equipment when the stall is not open. This has implications for the use of chiller cabinets, how long the stalls can be open for, and transport arrangements to and from the hospital. AtHairmyresandWishawhospitals,LCFHPhastosetupandtakedownthestalldaily,withtheequipmentandproducetransportedfromandtoLCFHP’spremises.Thisincursadditionalstaffingandtransportcostsandreducesthehoursthatthestallcanoperatefor.

AtMonklandsHospitalaunitwasfabricatedtoallowtheequipmenttobestoredandsecuredwhenthestallwasnotoperating. The community food initiatives are running these stalls with the aim of generating income for their organisations, and therefore attracting and retaining customers is essential. All of the community food initiatives described the importance of providing a wide range of high quality, fresh produce. They commented on the need to maintain the range and quality of their produce throughout their stalls’ operating hours, while minimising waste. It was reflected that ensuring both could be challenging.

While some of the community food initiatives received NHS funding to support the setting up of the stalls, this funding was time-limited, and all the stalls were (or are) expected to become financially self-sustaining. However, in order to continue to meet their responsibilities around the Health Promoting Health Service framework, hospitals and NHS Boards also need to guarantee the continued supply of fruit and vegetables. Therefore, they also have an interest in ensuring that their staff know about and purchase from the stalls.

Some of the stalls are making it easier for staff to purchase their produce, through use of ordering or delivery schemes.

CFINEandLCFHPbothoperateorderingsystemsforstaffworkinginthehospitals,throughthehospitals’intranet.Theseallowstafftoordertheirproduceinadvanceandensurethatthecommunityfoodinitiativescanpreparefreshordersasrequired.Wherethissystemisusedstafffeedbackhasbeenverypositive;however,take-upremainsgenerallyquitelow. In addition to promoting the stalls to individual staff members, some hospitals actively promote the service to their wards and other departments, to ensure that staff and patients are able to buy more fruit and vegetables. In one hospital, the fruit and vegetable stall is significantly increasing access to fruit and vegetables for patients as well as staff. ECF’swarddeliveryschemeintheRoyalEdinburghHospitalismakingiteasierforstafftopurchasefruitandvegetablesfromthestall.The£1‘5-a-day’bagsareverypopular.

Thedeliveryschemealsoenablesmorepatientstobuyfreshproduce,particularlythosethatneedtobeaccompaniedbyamemberofstaffiftheywishtoleavetheirwards.

Someofthewardsalsopurchasefruitandvegetablesfromthestallfortheirpatientstoeat,ortouseinfoodpreparationsessions. Some NHS Boards include regular items about the stalls in their staff newsletters, sometimes including discount vouchers. Some hospitals have produced publicity materials about their fruit and vegetable stall.

AswellaspromotingCFINE’sstallthroughthehospital’sintranet,NHSGrampianhasproducedpostersand‘tabletalkers’thatwillbeusedinthestaffcanteenatAberdeenRoyalInfirmary,andpull-upbannersthatareusedatDrGray’sHospitaltopromotebothorganisations. Gaining the support of medical staff has also resulted in more customers using the stalls managed by two community food initiatives.

ECFrunastalltwiceweeklyintheoncologydepartmentofonehospital,tocoincidewithoutpatientclinics.Anoncologyconsultantactivelyencouragespatientsattendinghisclinicstobuyfruitandvegetablesfromthestall.

Cardiology,oncologyanddiabetesconsultantsinthreeLanarkshirehospitalsoffer£1voucherstosomeoftheirpatients,whichareredeemableatthestallsrunbyLCFHP.LCFHPreceivesasmallamountoffundingtoreimbursethemforthecostoftheproduce.

HealthImprovementstaffatNHSLanarkshirehavealsobeenabletosupportoccasionalhalf-priceweeks,whichhaveprovedverypopular,andpromotethestalls.

Every community food initiative reported a fluctuation in sales throughout the year, sometimes significant. Sales are influenced by a range of factors, some predictable, some not. Sales tend to be higher in the summer when a wider range of fruit is available, particularly strawberries and other berry fruits. Holidays, such as Christmas, Easter and the ‘Fair Fortnights’ tend to reduce the amount of sales. Bad weather also affects all of the stalls, but particularly those that operate outdoors. To counter the fluctuation in sales, the community food initiatives have adopted a range of approaches to promote and market their services.

Inadditiontofruitandvegetables,REALalsosoldlocally-producedmeat,cheeseandpreserves.AswellassellingthefruitandvegetablesthatitgrewinitsmarketgardenatInvernessHighSchool,itsoldotherfreshproduce,sourcingasmuchaspossiblefromlocalproducers. To retain customers when there is less variety of fresh produce available, some stalls sell complementary products.

EdinburghCommunityFoodsellsdriedfruits,andorganicjamsandpreservesproducedonalocalfarmduringthewintermonths.ItsdriedcranberriesareaparticularfavouritewithcustomersnearChristmas. With one exception, the stalls were managed by paid members of staff. However, all of the community food initiatives rely on volunteer staff. Some of the community food initiatives highlighted difficulties in recruiting and retaining volunteers. They all acknowledged that relying on volunteers to staff their stalls could cause difficulties, particularly when they were unable to work as expected.

A range of methods were used to recruit volunteers.

ECFattractsanumberofstudentvolunteers,someofwhomworkonthehospitalstalls.ItadvertisesforvolunteersthroughtheCity’suniversitiesandalsousesthe‘Gumtree’website.

TheBigApplepreferstorecruitoldervolunteersastheytendtobemorecommittedtotheorganisation.Someofitsoldervolunteershavebeenwiththeorganisationformanyyears.

All of the community food initiatives provide training for the volunteers, appropriate for their role. This includes handling cash, displaying produce, and customer care. One organisation also ensures that the volunteers at one of its stalls are comfortable working with customers who may display differing needs or behaviours.

For some volunteers, being involved in the work of a stall can make a significant difference to their lives.

HelpingECFwithitsdeliveryschemeprovidesthepatientvolunteersattheRoyalEdinburghHospitalwiththeopportunitytotakepartinanactivitythatbenefitseveryone.Hospitalstaffhavecommentedontheimportanceofthedeliveryschemetothevolunteers,becauseitinvolvestheminactivitiesthataremeaningful.

Inaddition,thestallplaysanimportantpartinthelivesofsomeofthepatientsinthehospital.Beingabletovisitandbuyfromthestallhelpsto‘normalise’thehospitalexperienceforsome.

Conclusion

Community food initiatives and hospitals working together to establish fruit and vegetable stalls delivers a ‘win-win’ situation for everyone.

For NHS staff, the stalls are enabling them to meet national policy objectives, while supporting third sector organisations and, in some cases, providing an important service for their patients.

For community food initiatives, the stalls have the potential to assist them to generate income and become less dependent on grant funding.

For hospital staff, visitors and patients, the stalls are providing easier access to good quality, affordable fruit and vegetables.

In addition to this, feedback from staff at the Edinburgh Royal Hospital and ECF suggests there is potential for stalls to play an important role in the lives of patients in non-acute hospitals.

The stalls have all faced challenges: however, these can be minimised, as has been demonstrated by some of the examples included.

Some of the examples included demonstrate the fragility of the community food sector. In order to maintain some of the stalls until they are in a position to become financially self-sustaining, longer term financial support is required. However, this longer term support has the potential to deliver sustained benefits to the health and wellbeing of staff, and savings to health services in the future.

Contact details

TheBigAppleAlison Sellars Transform Community Development Unit K Mid Wynd Hawkhill Court Dundee, DD 01382 200040www.cyrenians.co.uk

CFINE(CommunityFoodInitiativesNorthEast)Fiona Rae 4 Poynernook Road Aberdeen, AB11 5RW 01224 596156www.cfine.org

EdinburghCommunityFoodKaren Miller 22 Tennant Street Edinburgh, EH6 5ND 0131 467 7326www.edinburghcommunityfood.org.uk

CommunityFoodMorayJo RobertsUnit 3Mosstodloch Service Station Mosstodloch, IV32 7JH01343 [email protected]

LanarkshireCommunityFoodandHealthPartnershipIan Shankland Unit 7 Strathclyde Business Park 391 Langmuir Road Bargeddie, 0141 771 [email protected]

REALFoodsIain Clyne Inverness High School Montague Row Inverness, IV3 5QZhttp://real-ihs.blogspot.com

StepwellSteven WatsonSuite 3, Clarence House1 Haig Street, Greenock, PA15 1JG01475 724038www.stepwell.org.uk

CommunityFoodandHealth(Scotland)c/oConsumerFocusScotland,RoyalExchangeHouse100QueenStreet,GlasgowG13DN

Tel:01412265261Fax:01412219695cfh@consumerfocus.org.ukwww.communityfoodandhealth.org.uk

community food initiatives retailing in hospitals and ......we hope that this publication will...

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